Don’t wait to act on opioid deaths, coroner warns in report on Quebec teen’s death

MONTREAL — The 2023 death of a Quebec teen who was poisoned from a synthetic opioid should raise alarm bells for authorities to do more to prevent similar tragedies, says a coroner’s report released this week.

Fifteen-year-old Mathis Boivin died after he consumed N-desethyl isotonitazene, a powerful synthetic opioid. Coroner Stéphanie Gamache ruled the death accidental — the teenager believed he had taken oxycodone, an opioid used for pain relief.

In addition to urging lawmakers to act, Gamache said it is a “social responsibility to recognize that preventing opioid and other psychoactive substance poisoning concerns us all.” Drug intoxication deaths are on the rise across North America, and Quebec is not immune from the problem, the coroner said in her report released Thursday.

“Mathis’s death should sound the alarm, because we should not wait for the accumulation of deaths among young people to make this observation.”

Gamache said young people should be better educated at school about the dangers of opioids and how to recognize if they or their peers are at risk of drug abuse. Regional health authorities say that while schools have access to drug-prevention programs, the way the programs are delivered varies widely.

Christian Boivin, the teen’s father, said he was satisfied with the report. If his son had been aware of the signs of an overdose, perhaps he would have come to his parents and they could have saved him, he said. “For me and Mathis, we were not prepared for an opioid overdose.”

Boivin has spent time doing outreach work himself — speaking to students in schools about opioid addiction and his first-hand experience. He would also like to see prevention measures be streamlined across all schools in the province.

“We need kids to know about drugs,” Boivin said. “They need to talk more and they need to know more about the risk of all the drugs on the market … fake pills and things like that.”

Jean-Sebastien Fallu, a professor at Université de Montreal, says the coroner could have gone further in her report. Instead of just recommending more drug prevention, she could have suggested that students have access to places where drugs can be tested for contaminants or for the presence of fentanyl, a powerful synthetic opioid.

“Drug use is a human experience since the beginning of time,” Fallu said.

“Drugs will always be there, we need to cope with them, not try to make like they’re not there or eliminate them … we need to get away from abstinence-only approaches.”

According to the report, Mathis had purchased around five to seven pills the afternoon before his death from a street dealer. He thought he had purchased oxycodone, but testing on the pills his parents found in his wallet did not detect oxycodone.

The night before he died, he dined with family and retired to his bedroom where he played an online game with a friend and told him he had taken some of the pills. He told the friend he felt itchy, like he had been bitten, and that he was tired.

The morning of Dec. 22, 2023, Mathis’s alarm clock had been ringing for some time when his father broke down the door, which was locked from inside, and found the boy unresponsive on his bed. Family and paramedics attempted to revive Mathis, who was in cardiac arrest. Ambulance technicians administered naloxone before rushing him to hospital. His death was confirmed in the emergency room.

A Health Canada analysis determined that the teenager had consumed N-desethyl isotonitazene, a synthetic opioid. The pathology report also found that he was suffering from bilateral bronchopneumonia, a lung infection. It was impossible to determine how much of the synthetic drug Mathis had taken.

In the months before his death, a friend had texted his father to express his worries about Mathis’s hard-drug consumption. His family knew he consumed cannabis, but Mathis denied taking hard drugs.

The coroner found there had been red flags regarding Mathis’s problems with drugs in the months before his passing. He may have been able to receive treatment, the coroner said, if his parents had been able to identify the warnings signs.

This report by The Canadian Press was first published Jan. 31, 2025.

Sidhartha Banerjee, The Canadian Press